Thoracic Vertebrae: Difference between revisions

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= Assessment  =
= Assessment  =


[[Thoracic Examination|Thoracic examination]] includes a subjective and an objective part.  
[[Thoracic Examination|Thoracic examination]] includes a subjective and an objective part. The objective part is here divided in Physical Therapy assessment and diagnostic imaging. 


=== Physical Therapy assessment  ===
=== Physical Therapy assessment  ===
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The sequence proposed by [[Maitland's Mobilisations|Maitland ]] for the physical examination of the intervertebral segment is: <ref name="Maitland">G.D. Maitland. Vertebral Manipulation. Fourth Edition. London-Boston: Butterworths, 1977.</ref><br>'''&nbsp; &nbsp;1. Active tests'''<br>&nbsp; &nbsp; &nbsp; a. Active movements.&nbsp;The active movements of the thoracic spine are usually done with the patient standing. <br>&nbsp; &nbsp; &nbsp; b. Auxiliary tests associated with active movements tests.<br><br>'''&nbsp; &nbsp;2. Passive tests'''<br>&nbsp; &nbsp; &nbsp; c. Movement of the pain-sensitive structures in the vertebral canal and intervertebral foramen. <br>&nbsp; &nbsp; &nbsp; d. Palpation.<br>&nbsp; &nbsp; &nbsp; e. Passive range or intervertebral movement. The joint play movements performed on the thoracic spine<span style="font-size: 13.28px;">&nbsp;were developed by Maitland and they are: Posteroanterior central vertebral pressure, p</span>osteroanterior unilateral vertebral pressure, transverse vertebral pressure and rib springing.<br>  
The sequence proposed by [[Maitland's Mobilisations|Maitland ]] for the physical examination of the intervertebral segment is: <ref name="Maitland">G.D. Maitland. Vertebral Manipulation. Fourth Edition. London-Boston: Butterworths, 1977.</ref><br>'''&nbsp; &nbsp;1. Active tests'''<br>&nbsp; &nbsp; &nbsp; a. Active movements.&nbsp;The active movements of the thoracic spine are usually done with the patient standing. <br>&nbsp; &nbsp; &nbsp; b. Auxiliary tests associated with active movements tests.<br><br>'''&nbsp; &nbsp;2. Passive tests'''<br>&nbsp; &nbsp; &nbsp; c. Movement of the pain-sensitive structures in the vertebral canal and intervertebral foramen. <br>&nbsp; &nbsp; &nbsp; d. Palpation.<br>&nbsp; &nbsp; &nbsp; e. Passive range or intervertebral movement. The joint play movements performed on the thoracic spine<span style="font-size: 13.28px;">&nbsp;were developed by Maitland and they are: Posteroanterior central vertebral pressure, p</span>osteroanterior unilateral vertebral pressure, transverse vertebral pressure and rib springing.<br>  


==== Abnormal postures ====
==== Visual examination of abnormal postures ====


*'''Kyphosis''':&nbsp;When the thoracic spine is viewed from the side, it is seen to have an anterior concavity and posterior convexity, and when looked at from behind, should theoretically descend in the postrior midline.&nbsp;In certain cases, such as in elderly people, the anterior concavity of the thoracic spine is exaggerated, and this is termed [[Thoracic Hyperkyphosis|hyperkyphosis]]&nbsp;or&nbsp;[[Age-related hyperkyphosis|age-related&nbsp;kyphosis]]. Kyphosis is a condition thata is most prevalent in the thoracic spine. The kyphotic individual presents with a stooped posture and this has implications on thoracic expansion.
*'''Kyphosis''':&nbsp;When the thoracic spine is viewed from the side, it is seen to have an anterior concavity and posterior convexity, and when looked at from behind, should theoretically descend in the postrior midline.&nbsp;In certain cases, such as in elderly people, the anterior concavity of the thoracic spine is exaggerated, and this is termed [[Thoracic Hyperkyphosis|hyperkyphosis]]&nbsp;or&nbsp;[[Age-related hyperkyphosis|age-related&nbsp;kyphosis]]. Kyphosis is a condition thata is most prevalent in the thoracic spine. The kyphotic individual presents with a stooped posture and this has implications on thoracic expansion.
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=== Diagnostic imaging  ===
=== Diagnostic imaging  ===


Imaging is most often performed after a trauma when there is risk of fracture. It is not the first technique of choice for the diagnosis of thoracic spine pain.The most commonly injured levels durint an important trauma in the spine are the cervicothoracic (C6, C7, T1, T2) and thoracolumbar (T11, T12, L1, L2) vertebrae. These segments are predisposed to mechanical forces because they are the transitional areas between the relatively fixed (via the rib cage) thoracic spine and the more mobile cervical and lumbar spines.<ref name="FA">F.A. Davis PT Collection. Imaging the thoracic spine. http://fadavispt.mhmedical.com/content.aspx?bookid=1871&amp;sectionid=137819150. (accessed 17 april 2017).</ref>
Imaging is most often performed after a trauma when there is risk of fracture. It is not the first technique of choice for the diagnosis of thoracic spine pain.The most commonly injured levels durint an important trauma in the spine are the cervicothoracic (C6, C7, T1, T2) and thoracolumbar (T11, T12, L1, L2) vertebrae. These segments are predisposed to mechanical forces because they are the transitional areas between the relatively fixed (via the rib cage) thoracic spine and the more mobile cervical and lumbar spines.<ref name="FA">F.A. Davis PT Collection. Imaging the thoracic spine. http://fadavispt.mhmedical.com/content.aspx?bookid=1871&amp;amp;sectionid=137819150. (accessed 17 april 2017).</ref>  


*'''Computed tomography ''''''(CT).''' CT is the initial imaging study for high-risk trauma patients, for example, in cases of multiple system trauma.<ref name="medscape">Medscape.Thoracic Spinal Trauma Imaging.http://emedicine.medscape.com/article/397896-overview. (accessed 17 april 2017).</ref>&nbsp;<ref name="FA" />
*'''Computed Tomography'''&nbsp;'''(CT).''' CT is the initial imaging study for high-risk trauma patients, for example, in cases of multiple system trauma.<ref name="medscape">Medscape.Thoracic Spinal Trauma Imaging.http://emedicine.medscape.com/article/397896-overview. (accessed 17 april 2017).</ref>&nbsp;<ref name="FA" />  
*'''Radiography'''. Radiographs are the initial imaging study for thoracic spine problems, with the exception of high-risk trauma patients, who are evaluated by CT. However, if CT is not available, radiographs are indicated.&nbsp;<ref name="FA" />
*'''Radiography'''. Radiographs are the initial imaging study for thoracic spine problems, with the exception of high-risk trauma patients, who are evaluated by CT. However, if CT is not available, radiographs are indicated.&nbsp;<ref name="FA" />


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*'''Magnetic resonance imaging (MRI)'''.&nbsp;MRI is superior to both radiography and CT in the detection of soft tissue injury to the ligaments, facet capsules, and prevertebral spaces.&nbsp;<ref name="medscape" /><br>
*'''Magnetic resonance imaging (MRI)'''.&nbsp;MRI is superior to both radiography and CT in the detection of soft tissue injury to the ligaments, facet capsules, and prevertebral spaces.&nbsp;<ref name="medscape" /><br>


{{#ev:youtube|7SIry1QXNsA}}
{{#ev:youtube|7SIry1QXNsA}}  


=== Outcome Measures  ===
=== Outcome Measures  ===

Revision as of 17:40, 17 April 2017

Clinically Relevant Anatomy[edit | edit source]

Thoracic Spine

The thoracic spine is part of the vertebral column that supports the chest area and provides posterior attachment for the ribs, some thoracic wall muscles, muscles of the upper limb abdomen and back. The thoraci spine lies between the cervical spine superiorly and the lumbar spine inferiorly. It consists of 12 thoracic vertebrae that are in some ways distinct from vertebrae found in other regions of the vertebral column


Bodies[edit | edit source]

The bodies of the thoracic vertebrae are medium sized and heart shaped. They are all weight bearing and generally increase in size from up downwards with an increase in the amount of weight that needs to be supported. The heads possess articular facets on their sides for articulation with the heads of the ribs

Pedicles[edit | edit source]

These project from the posterolateral surfaces of the bodies of the ribs and meet posteriorly with the laminae. The pedicles and laminae on either side form the neural arch which together with the posterior surface of the body enclose the vertebral formen. The pedicles are notched on their superior and inferior surfaces, in the articlated thoracic spine, these notches form the intervertebral foramina for the passage of the thoracic spinal nerves


Laminae[edit | edit source]

Run posteriorly from their junction with the pedicles and and meet in the posterior midline to form the spinous process of each thoracic veretebra

Transverse process[edit | edit source]

There are two for each veretebra, these are long and thin and provide an articular surface for the tubercle of the rib as well as attachment sites for ligaments and mucles of the thoracic region. They run laterally from the junction between the pedicle and the lamina on either side.

Articular processes[edit | edit source]

Each veretebra has a superior articular process on each side that has a smooth surface (articular facet) for articulation with the corresponding inferior articular facet of the inferior articular process of the superior vertebra. Each vertebra also has an inferior articulat process on either side that articulates with corresponding superior processes of the subjacent vertebra. Superior articular facets of the thoracis region face posteriorly and laterally, the inferior facets face forward and medially. This arrangement permits rotation to occure between the vertebrae

Vertebral canal[edit | edit source]

The body and neural arch of each vertebra enclose the vertebral foramen, in an articulated thoracic spine, the vertebral foramina of the stacked vertebrae form a continuous vertebral canal for the passage of the spinal cord and the meninges surrounding it, as well as the arteries and veins supplying these structures. In the thoracic spine, the vertebral foramina are small and circular and this has obvious implications on the spinal cord. The spinal cord in the adult terminates at or around the level of the lower border of the first lumbar vertebra meaning it traverses the entire thoracic spine. Slightly excessive movements of one vertebra relative to another in the thoracic region run a huge risk of compressing the spinal cord and leading to damage of the cord

Spinous process[edit | edit source]

The spinous processes of thoracic vertebra project posteriorly but mainly downwards. In palpation of the posterior midline in the thoracic region, it will be important to note that the tip of the thoracic spine will lie level with the body of the subjacent vertebra, for example, the spine of the seventh thoracic vertebra C7 will lie roughly at the level of the body of the eighth thoracic vertebra C8


Assessment[edit | edit source]

Thoracic examination includes a subjective and an objective part. The objective part is here divided in Physical Therapy assessment and diagnostic imaging. 

Physical Therapy assessment[edit | edit source]

The sequence proposed by Maitland for the physical examination of the intervertebral segment is: [1]
   1. Active tests
      a. Active movements. The active movements of the thoracic spine are usually done with the patient standing.
      b. Auxiliary tests associated with active movements tests.

   2. Passive tests
      c. Movement of the pain-sensitive structures in the vertebral canal and intervertebral foramen.
      d. Palpation.
      e. Passive range or intervertebral movement. The joint play movements performed on the thoracic spine were developed by Maitland and they are: Posteroanterior central vertebral pressure, posteroanterior unilateral vertebral pressure, transverse vertebral pressure and rib springing.

Visual examination of abnormal postures[edit | edit source]

  • Kyphosis: When the thoracic spine is viewed from the side, it is seen to have an anterior concavity and posterior convexity, and when looked at from behind, should theoretically descend in the postrior midline. In certain cases, such as in elderly people, the anterior concavity of the thoracic spine is exaggerated, and this is termed hyperkyphosis or age-related kyphosis. Kyphosis is a condition thata is most prevalent in the thoracic spine. The kyphotic individual presents with a stooped posture and this has implications on thoracic expansion.

Scheuerman's disease is the most commont structural kyphosis in adolescents but can occur in adults. Its etiology is unknow.[2]

Hump back is a localized, sharp, posterior anagulation called a gibbus. This kyphotic deformity is usually structural and often results from an anterior wedging of the body of one or two thoracic vertebrae. Dowagers's hump results from postmenopausal osteoporosis: anterior wedge fractures occur to several vertebrae, usually in the upper to middle thoracic spine, causing a structural scoliosis that also contributes to a decreise in heigh.[2]

  • Scoliosis: The thoracic spine may also be curved laterally when viewed from behind. Usually there is a concavity to one side in the thoracic spine and a 'compensatory' concacity to the opposite side in the lumbar spine, and this may be considered normal. However, in certain cases, these curvatures are exaggerated and this is termed scoliosis.

Diagnostic imaging[edit | edit source]

Imaging is most often performed after a trauma when there is risk of fracture. It is not the first technique of choice for the diagnosis of thoracic spine pain.The most commonly injured levels durint an important trauma in the spine are the cervicothoracic (C6, C7, T1, T2) and thoracolumbar (T11, T12, L1, L2) vertebrae. These segments are predisposed to mechanical forces because they are the transitional areas between the relatively fixed (via the rib cage) thoracic spine and the more mobile cervical and lumbar spines.[3]

  • Computed Tomography (CT). CT is the initial imaging study for high-risk trauma patients, for example, in cases of multiple system trauma.[4] [3]
  • Radiography. Radiographs are the initial imaging study for thoracic spine problems, with the exception of high-risk trauma patients, who are evaluated by CT. However, if CT is not available, radiographs are indicated. [3]
  • Magnetic resonance imaging (MRI). MRI is superior to both radiography and CT in the detection of soft tissue injury to the ligaments, facet capsules, and prevertebral spaces. [4]

Outcome Measures[edit | edit source]

add links to outcome measures here (also see Outcome Measures Database)


Treatment[edit | edit source]

Physiotherapy[edit | edit source]

Exercise[edit | edit source]

Is beneficial in situations of kyphosis, osteoporosis, stiffness, etc.

Manipulation[edit | edit source]

There is no much research literature on the safety of joint manipulation when applied to the thoracic spine. Thrust joint manipulation should never be performed when contraindications or precautions are present.[5]

Absolute contraindications to performing thrust joint manipulation (TJM) to the thoracic spine
Bony issues
 Any pathology that may have led to bony compromise
  Tumour, e.g. metastatic disease
  Infection, e.g. tuberculosis, osteomyelitis
  Metabolic, e.g. osteomalacia, osteoporosis
  Congenital, e.g. dysplasias, congenital fusions
  Iatrogenic, e.g. long-term corticosteroid medication, surgical fusions, recent surgery
  Inflammatory, e.g. rheumatoid arthritis, ankylosing spondylitis, acute soft tissue injury, connective tissue disease, synovial cysts
  Traumatic, e.g. fracture, dislocation,   ligamentous rupture, instability
Neurological issues
 Any pathology that may affect the neurological system
  Acute cervical, thoracic or lumbar myelopathy
  Spinal cord compression
  Cauda equina syndrome
  Nerve root compression with increasing neurological deficit, bilateral hyper-reflexia/sensory loss
  Sudden vomiting/nausea/vertigo
Vascular issues
 Any pathology that may have led to vascular compromise
  Diagnosed vertebrobasilar insufficiency or cervical artery abnormalities
  Aortic aneurysm
  Bleeding diatheses, e.g. haemophilia, anticoagulant therapy
  Angina pectoris
  Untreated cardiac insufficiency, untreated cardiac dysthymias
  Acute abdominal pain with guarding
Clinical issues
 Any matter that may increase the risk of harm to the patient
  Lack of adequate subjective and objective examination by clinician
  Lack of diagnosis
  Lack of skill/expertise by clinician
  Lack of consent from the patient


Relative precautions to performing thrust joint manipulation (TJM) to the thoracic spine
Adverse reaction to previous TJM
Inflammatory joint processes
Minor osteoporosis
Disc herniation and disc protrusion
Spondylolisthesis
Hypermobility or ligamentous laxity
Arterial calcification
Arterial hypertension
Serious degenerative joint diseases
Growing children
Serious kyphosis and scoliosis
Herpes zoster on the thoracic spine
Vertigo
Systemic infections
Psychological dependence upon manipulation
Pain with a psychological overlay
No change or worsening of symptoms after multiple manipulations


Surgery[edit | edit source]

Surgery can be needed when fracture injury.
Although high risk needs to be warned, corrective surgery can achieve satisfactory results for focal kyphosis in upper thoracic spine.[6]

References[edit | edit source]

  1. G.D. Maitland. Vertebral Manipulation. Fourth Edition. London-Boston: Butterworths, 1977.
  2. 2.0 2.1 Magee DJ. Orthopedic Physical Assessment. Canada. .Elsevier 2014.
  3. 3.0 3.1 3.2 F.A. Davis PT Collection. Imaging the thoracic spine. http://fadavispt.mhmedical.com/content.aspx?bookid=1871&amp;sectionid=137819150. (accessed 17 april 2017).
  4. 4.0 4.1 Medscape.Thoracic Spinal Trauma Imaging.http://emedicine.medscape.com/article/397896-overview. (accessed 17 april 2017).
  5. Puentedura EJ, O'Grady WH. Safety of thrust joint manipulation in the thoracic spine: a systematic review. J Man Manip Ther 2015;23:154-161.
  6. Zeng Y, Chen Z, Guo Z, Qi Q, Li W, Sun C. The posterior surgical treatment for focal kyphosis in upper-middle thoracic spine. European Spine Journal 2014; 23:2291-2298.